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Subintimal dissection/reentry techniques are increasingly being used for crossing coronary chronic total occlusions both antegradely (using a knucle wire or the Bridgepoint system) or retrogradely (using the controlled antegrade and retrograde tracking and dissection, and reverse controlled antegrade and retrograde tracking and dissection technique). Subintimal dissection/reentry techniques can increase procedural success rates, but their subsequent clinical outcomes are poorly studied, and they appear to be associated with high rates of in-stent restenosis and repeat target lesion revascularization. In the present review, we describe in detail the chronic total occlusions subintimal dissection/reentry techniques, clarify the related terminology and summarize the published studies in this area and the current gaps of knowledge.
Every percutaneous coronary intervention carries risk for acute and long-term complications. This is also true of chronic total occlusion (CTO) interventions, which can also have complications specific to specialized techniques, such as retrograde crossing and dissection/reentry techniques. Acute CTO intervention complications can be coronary artery-related, cardiac noncoronary, or noncardiac. In the long term, CTO interventions can be complicated by in-stent restenosis, stent thrombosis, or coronary aneurysm formation. Understanding of the pathogenesis of possible CTO intervention complications can facilitate prevention, early recognition, and prompt treatment.
The GuideLiner catheter is an easy-to-use guide catheter extension that can facilitate vessel engagement and equipment delivery. We present two cases that illustrate two potential challenges associated with use of the GuideLiner catheter: (1) stent loss and deformation during attempts to advance it through the GuideLiner catheter collar; and (2) displacement of the GuideLiner catheter distal marker into a coronary artery. Awareness of these potential complications may render safer the use of this valuable interventional tool.
Failure to deliver stents is one of the commonest causes of procedural failure in contemporary PCI practice. We describe successful use of the Guideliner Catheter, the first purpose designed FDA and CE marked device delivery catheter in 13 complex cases in native coronary vessels and bypass grafts performed via the radial route to enable distal stent delivery following failure of conventional techniques. We discuss how the Guideliner catheter may be used to facilitate difficult radial cases. © 2010 Wiley-Liss, Inc.
This study sought to examine the efficacy and safety of 3 novel devices to recanalize coronary chronic total occlusions (CTOs).
Successful percutaneous coronary intervention (PCI) of CTOs improves clinical outcome in appropriately selected patients. CTO PCI success, however, remains suboptimal.
A new crossing catheter and re-entry system was evaluated in a prospective, multicenter, single-arm trial of CTO lesions refractory to standard PCI techniques. The primary efficacy endpoint was the frequency of true lumen guidewire placement distal to the CTO (technical success).
Enrollment included 147 patients with 150 CTOs. The mean lesion length was 41 ± 17 mm. A crossing catheter crossed 56 lesions into the distal true lumen, and a re-entry catheter facilitated tapered-wire cannulation of the distal lumen in 59 CTOs initially crossed subintimally (77% technical success). Success in the first 75 CTOs was 67%, rising to 87% in the last 75 CTOs. Mean fluoroscopy and procedure times were 45 ± 16 min and 90 ± 12 min, respectively, each significantly shorter than in historical controls (p < 0.0001 for both). Coronary perforation occurred in 14 cases (9.3%), requiring treatment in 3 cases (prolonged balloon inflation, with additional coil embolization in 1 case). No tamponade or hemodynamic instability occurred. Six patients had periprocedural non-ST-segment elevation myocardial infarction. No emergency surgery, ST-segment elevation myocardial infarction, or cardiac reintervention occurred. Two deaths occurred within 30 days, neither as a direct result of the procedure. The 30-day major adverse cardiac event rate was 4.8%.
In CTOs failing standard techniques, use of a new crossing and re-entry system results in a high success rate without increasing complications.
Coronary chronic total occlusions (CTOs) are frequently identified during coronary angiography and remain the most challenging lesion group to treat. Patients with CTOs are frequently left unrevascularized due to perceptions of high failure rates and technical complexity even if they have symptoms of coronary disease or ischemia. In this review, the authors describe a North American contemporary approach for percutaneous coronary interventions for CTO. Two guide catheters are placed to facilitate seamless transition between antegrade wire-based, antegrade dissection re-entry-based, and retrograde (wire or dissection re-entry) techniques, the "hybrid" interventional strategy. After dual coronary injection is performed, 4 angiographic parameters are assessed: 1) clear understanding of location of the proximal cap using angiography or intravascular ultrasonography; 2) lesion length; 3) presence of branches, as well as size and quality of the target vessel at the distal cap; and 4) suitability of collaterals for retrograde techniques. On the basis of these 4 characteristics, an initial strategy and rank order hierarchy for technical approaches is established. Radiation exposure, contrast utilization, and procedure time are monitored throughout the procedure, and thresholds are established for intraprocedural strategy conversion to maximize safety, efficiency, and effectiveness.
Chronic total occlusion recanalization still represents the final frontier in percutaneous coronary intervention. Retrograde chronic total occlusion recanalization has recently become an essential complement to the classical antegrade approach. In experienced hands, the retrograde technique currently has a high success rate with a low complication profile, despite frequent utilization in the most anatomically and clinically complex patients. Since its initial description, important changes have occurred that make the technique faster and more successful. We propose a step-by-step approach of the technique as practiced at experienced centers in North America. Because the technique can vary substantially, we describe the different alternatives to each step and offer what we perceived to be the most efficient techniques.
The retrograde approach has revolutionized the treatment of chronic total occlusions. Several retrograde techniques have recently been described. In this article, we present a practical review with step-by-step instructions on the indications for retrograde interventions, equipment and retrograde channel selection, and techniques for retrograde crossing and treatment of chronic total occlusions.
We describe treatment of six chronic total occlusions due to in-stent restenosis with the CrossBoss catheter (BridgePoint Medical, Minneapolis, Minnesota). The CrossBoss catheter allowed successful CTO crossing in 5 of 6 lesions (83%): in 50% the catheter entered the distal true lumen, whereas in 33% a wire was required for distal true lumen crossing. No complications were observed. Use of the CrossBoss catheter can facilitate treatment of coronary chronic total occlusions due to in-stent restenosis.
The GuideLiner catheter (Vascular Solutions, Minneapolis, MN) is a novel, rapid exchange catheter that allows deep vessel intubation. We describe 21 patients in whom the GuideLiner catheter [7 French (F) in 76% and 6F in 24%] was used to facilitate equipment delivery (n = 14) or vessel engagement (n = 7). Pressure dampening after GuideLiner catheter insertion was observed in 12 patients (57%). The procedure was successfully completed in 19 patients (90%) and one patient developed acute vessel closure, likely due to dissection. The GuideLiner catheter can facilitate complex coronary interventions but should be used with caution to minimize the risk for vessel injury.
Covered stents have shown discouraging results when tested on saphenous vein grafts and when attempting to prevent restenosis on native coronary arteries. However, covered stents seem to be a unique tool when a coronary artery perforation complicates percutaneous coronary intervention. Because a randomized clinical trial is not likely to be conducted in this bail-out scenario, the data supporting its use come from case reports and small-size retrospective studies. This review summarizes the available evidence supporting the use of covered stents to treat coronary perforations.
This case report describes the nonsurgical management of a distal LAD perforation and is accompanied by a brief review of the different techniques available for sealing off a persistent leak in a perforated distal vessel. Coiling and embolic devices are particularly useful to seal distal perforations owing to their low profile and maneuverability.
To evaluate procedure outcomes, complications, and the predictors of device success while using the Tornus in CTO revascularization.
The success of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) may be limited by the presence of severe calcified CTO lesions, especially in the smallest balloon uncrossable arteries. A penetrating device (Tornus) could improve the success rate.
Device and angiographic success rates as well as procedural complications were assessed in 56 patients, who were consecutively and retrospectively enrolled into this study. Device success was defined as successful passage of the Tornus catheter through a CTO lesion. Procedure success was defined by a final TIMI 3 flow and <30% residual stenosis.
The device success rate was 71.4% in 40 patients and failure rate was 28.6% in 16 patients. The final procedure success was significantly higher in the Tornus success group compared with the Tornus failure group (87.5% vs. 37.5%, P < 0.001). One patient in the Tornus success group (1.8%) had wire perforation resulting in cardiac tamponade and cardiac death. Another patient (1.8%) in the Tornus success group had acute in-stent thrombosis and non-Q MI in 24 hr and was resuscitated by emergent PCI. The only independent predictor of device success was a calcium score < 2 (odds ratio (OR): 3.86 (95% CI: 1.14-13.1, P = 0.03).
The Tornus catheter can be used in severe calcified CTO PCI when the calcium score <2 and not be used in patients with a calcium score ≥2.
We report a novel technique for retrograde chronic total occlusion intervention, in which the lesion is crossed by forming and advancing a "knuckle" in both the antegrade and retrograde guidewire, followed by reentry in the true lumen by using the Stingray re-entry system.
In view of the improved long-term patency with drug-eluting stents, the challenge with chronic total coronary occlusion remains a low primary success rate. Modes of failure to open a chronic total coronary occlusion are mainly related to the inability to pass a wire through the proximal occlusion cap, and the most difficult part of the procedure is to guide the wire into the distal true lumen. A frequent situation is a subintimal wire position. The BridgePoint (BridgePoint Medical, MN, USA) family of devices is designed to cope with both of these problems. First, the CrossBoss™ catheter aims at passing through the proximal cap by manual rotation of a blunt proximal tip, and second, in case of a subintimal position, the Stingray™ balloon enables guided reentry from the subintimal space into the true lumen. Certain features of an occlusion might favor the CrossBoss device, while the reentry approach may also be used as a standalone bailout method. The aim is to provide a means to resolve otherwise failed attempts and to make it unnecessary to resort to the more complex and time-consuming retrograde wire techniques through collateral channels with the associated potential higher procedural risks.
We report two cases of flush chronic total occlusion due to in-stent restenosis, in which percutaneous coronary intervention attempts via over-the-wire balloons and microcatheters failed to cross the lesion. Using the Venture catheter for support and the Stingray guidewire for enhanced penetration capacity, both lesions were successfully crossed and stented.
The Venture catheter (St Jude, Minneapolis, MN) has a deflectable tip for facilitating wire steering and a stiff body. Both properties can be useful in percutaneous coronary interventions (PCI) of coronary chronic total occlusions (CTOs).
We reviewed 26 consecutive patients in whom the Venture catheter was utilized during coronary CTO PCI at our institution between May 2008 and September 2009.
Mean age was 63 ± 9 years and 96% of the patients were men. The CTO target lesion was located in the right coronary artery (35%), left anterior descending artery (27%), circumflex (27%) or a saphenous vein graft (4%). A prior attempt for CTO PCI had been done in 19%. The primary CTO PCI approach was antegrade in 92% and retrograde in 8%, but a retrograde approach was used in an additional 27% of the patients after antegrade approach failed. The Venture catheter was used to overcome vessel tortuosity (73%), for CTOs with side branch at the occlusion site (15%), to facilitate collateral branch wiring during retrograde PCI (8%), and to provide extra support (4%). The overall CTO PCI success rate was 77% and was 92% in patients with upfront Venture catheter use and in 64% of patients in whom the Venture was used after PCI attempts using other equipment failed. Procedural failure was due to inability to cross the lesion in all cases.
The Venture catheter can facilitate CTO PCI, especially in patients with marked coronary tortuosity or when additional support is required.
The aim of this study was to report the initial experience with a novel catheter in the retrograde approach for chronic total occlusion (CTO).
Although the use of the retrograde approach in percutaneous coronary intervention for CTO has been established, some procedural difficulties remain.
A novel over-the-wire catheter (channel dilator) specifically designed for the retrograde approach has been developed for the treatment of CTO. The channel dilator was used in 93 CTO lesions after successful wiring of collateral channels using the retrograde approach.
Successful channel crossing of the catheter was achieved in 90 of the lesions (96.8%), and the channel dilator successfully advanced into the occlusion reversely during retrograde wiring in 85 lesions (94.4%). Of the 75 lesions with successful advancement of the retrograde wire into the proximal true lumen, the entire occlusion was crossed retrograde with the channel dilator in 63 lesions (84.0%). To evaluate the feasibility of the catheter, 93 CTO lesions in the preceding period were compared. Procedure and fluoroscopy time tended to be lower in the study group than in the control group. The success of the retrograde procedure was significantly higher in the study group than in the control group (98.9% vs. 92.5%, p = 0.030).
The channel dilator may facilitate the conventional retrograde approach with a high level of success.
To evaluate the outcome of patients with coronary perforations who were treated with the dual catheter approach.
Coronary artery perforation is a grave complication of percutaneous coronary intervention (PCI) with high mortality and morbidity. Treating a coronary artery perforation with two catheters through dual access enables a rapid delivery of covered stent or coils to the vessel, without losing control of the perforation site.
We retrospectively reviewed all patients who had a severe coronary perforation during a PCI in our center, and compared outcomes of patients treated with the dual versus the traditional single guiding catheter approach.
Between April 2004 and October 2008, 13,466 PCI's were performed in Columbia University - New York Presbyterian Medical Center. There were 33 documented cases of coronary perforations during that period of time (0.245%), among these, 26 were angiographically severe (Ellis type 2 or 3 perforations). Eleven patients were treated acutely with a dual catheter technique whereas the other fifteen patients were treated using a single guiding catheter. In the dual catheter group one patient expired after emergent CABG (9.1%), and four patients underwent emergent paricardiocentesis (36.4%). In patients treated with single catheter, there were three deaths (20%), two surgical explorations (13.3%), eight emergent pericardiocenthesis (53.3%), and one event of severe anoxic brain damage (6.7%).
The dual catheter technique is a relatively safe and reproducible approach to treat a PCI induced severe coronary artery perforation, and may improve outcome compared to historical series.
To describe the impact of a steerable device on procedural success and times. The Venture wire control catheter (VWC-St. Jude Medical, Maple Grove, MN, U.S.A.), facilitates wire orientation providing excellent backup support and may therefore assist in cases in which conventional approaches have failed.
We describe all cases in which the VWC catheter was used at our institutions. The device was employed after prolonged attempts with standard wires had failed. We analysed procedural success and complication rates, as well as the impact of this device on procedural times. We evaluated 18 cases. The mean time from the first wire attempt to the end of the procedure was 58 minutes. Lesion crossing attempts with standard wires were performed for a mean time of 23 minutes (range 10-45 minutes). The VWC catheter was employed as the last resort, leading to procedural success in 14 cases. Lesion crossing with the VWC catheter was achieved in a mean time of four minutes (range one to 15 minutes). There were no device-related complications.
Our experience shows how the VWC catheter can turn procedural failures into successes, significantly impacting procedural times in different challenging scenarios. This device may represent an extremely useful addition to the interventionalist's armamentarium.
Retrograde approach via collateral channels in coronary angioplasty for chronic total occlusion (CTO) can improve the success rate. Most interventionists will meet a few cases where the retrograde approach will provide unequaled advantages, but many are held back from taking retrograde approach by lack of proper equipment and expertise. In this article, we give detail description of techniques to shorten the guiding catheter, to traverse the collateral channels, and to cross the CTO. We also illustrate the difficulties in collateral channel crossing with different examples providing a basic guide for case selection purposes. We hope that many others would find rewardingly successful cases of retrograde approach CTO percutaneous coronary intervention, as in our experience.
We wished to test the safety and efficacy of a novel wire control catheter for use during percutaneous coronary intervention. The ability to vary the angulation of the tip of an intravascular guidewire would often be desirable. Previous attempts to produce deflectable-tip guidewire systems have met with limited success. The Venture wire control catheter (Velocimed, Minneapolis, MN) was used to facilitate percutaneous coronary intervention in 20 patients. There were no device-related complications. Percutaneous coronary intervention was successful in all patients. Our initial experience with the Venture wire control catheter has been favorable.
We present two patients with angulated, proximal left circumflex lesions, one a chronic total occlusion and one an acute subtotal occlusion. In both cases, use of the deflectable tip Venture Catheter (Velocimed, Minneapolis, MN) facilitated guide wire passage and successful percutaneous coronary intervention (PCI) after prior attempts at guide wire passage with standard wires were unsuccessful.
Renal artery aneurysms are rare vascular anomalies in which rupture is associated with devastating consequences. Only a few reported cases involved percutaneous treatment. Recently, technological advances have expanded indications for percutaneous treatment of such complex peripheral lesions. Despite this, certain anatomical settings such as extreme vessel tortuosity or angulation of the afferent vessel continue to pose challenges. New steerable devices may play a crucial role in those cases where conventional techniques have failed. We report a case of successful percutaneous treatment of a renal artery aneurysm and stenosis in a young male using the Venture catheter.
The essential equipment for CTO interventions
- Brilakis